¿Es precisa la ecografía para el diagnóstico de pólipos vesiculares? Revisión de las piezas de colecistectomía de pacientes diagnosticados de pólipo vesicular durante un periodo de 14 años / Is ultrasonography accurate for the diagnosis of gallbladder polyps? A review of cholecystectomy specimens from patients diagnosed with gallbladder polyps over a 14 years period

Introducción: La incidencia de pólipos vesiculares es del 0,3-12%. Es importante diferenciar los seudopólipos (pólipos de colesterol, adenomiomatosis o pólipos inflamatorios) de los pólipos verdaderos (adenomas y adenocarcinomas). Los principales factores de riesgo de malignización son el tamaño superior a 6-10mm, crecimiento rápido del mismo, morfología sésil, etnia india y colangitis esclerosante primaria. La ecografía es el gold standard para su diagnóstico. Sin embargo, la mayoría de los pólipos diagnosticados por ecografía son seudopólipos. El objetivo del estudio es analizar si la ecografía es precisa para diagnosticar los pólipos verdaderos en los pacientes cuya indicación quirúrgica ha sido este diagnóstico ecográfico. Métodos: Estudio observacional retrospectivo de los pacientes intervenidos en nuestro centro, desde el año 2007 al 2019, de colecistectomía electiva por presentar pólipos vesiculares. La cirugía se indicó en pacientes sintomáticos y/o con factores de riesgo. El estudio fue aprobado por el Comité Ético de Investigación Clínica de nuestro hospital. Resultados: Se han incluido 124 pacientes. En todos ellos se ha realizado colecistectomía laparoscópica. La edad media fue de 55,4 años y el 61% eran mujeres. El 65% tenían síntomas biliares. En nuestro estudio, solo 3 pacientes presentaron pólipos verdaderos (2,4%). Todos ellos, fueron adenomas tubulares. El resto de los pacientes resultaron falsos positivos (97,6%). El tamaño de los adenomas fue de 11, 6 y 5mm. La cirugía se indicó por tamaño o por clínica asociada. Conclusiones: La ecografía no es precisa para el diagnóstico de pólipos vesiculares verdaderos. La validación de otras pruebas complementarias para el diagnóstico de pólipos en pacientes asintomáticos podría ser relevante para evitar cirugías innecesarias. (AU)

Introduction: The incidence of gallbladder polyps is 0,3-12%. It is important to differentiate pseudopolyps (cholesterol polyps, adenomyomatosis, inflammatory polyps), which do not have the potential to become malignant, and true polyps (adenomas and adenocarcinomas). The main risk factors for malignancy are size>6-10mm, rapid growth, sessile morphology, Indian ethnicity and primary sclerosing cholangitis. Ultrasound is the gold standard for diagnosis. However, most polyps diagnosed by ultrasound are pseudopolyps. The main objective of this study is to analyze whether ultrasound is accurate for diagnosing true polyps in patients undergoing surgery for this reason. Methods: We conducted a retrospective observational study with prospective data entry of patients undergoing elective cholecystectomy for gallbladder polyps from 2007 to 2021. Surgery was indicated in symptomatic patients and in those with risk factors. The study was approved by the Clinical Research Ethics Committee of our hospital. Results: Our study included 124 patients who had undergone elective laparoscopic cholecystectomy. Mean age was 55.4 years, and 61% were women. In total, 65% were symptomatic at diagnosis. Only 3 patients had true polyps (2.4%), all of which were tubular adenomas. The remainig patients were false positives (97.6%). The adenoma sizes were 11, 6 and 5mm, respectively. The surgical indication was due to polyp size or due to associated biliary symptoms. Conclusion: Ultrasonography is not accurate for the diagnosis of gallbladder polyps. The validation of other complementary tests for the diagnose gallbladder polyps in asymptomatic patients could be relevant to avoid unnecessary surgeries. (AU)

Is ultrasonography accurate for the diagnosis of gallbladder polyps? A review of cholecystectomy specimens from patients diagnosed with gallbladder polyps over a 14-years period.

INTRODUCTION: Incidence of gallbladder polyps is 0,3-12%. It is important to differentiate pseudopolyps (cholesterol polyps, adenomyomatosis, inflammatory polyps), which do not have the capacity to become malignant, from true polyps (adenomas and adenocarcinomas). The main risk factors for malignancy are >6-10 mm, growth, sessile morphology, Indian ethnicity and primary sclerosing cholangitis. Ultrasound is the gold standard for diagnosis. Most polyps diagnosed by ultrasound are pseudopolyps. The main objective of this study is to analyse whether ultrasound is accurate for diagnosing true polyps in patients undergoing surgery for this reason. METHODS: Retrospective observational study with prospective data entry of patients undergoing elective cholecystectomy for gallbladder polyps from 2007 to 2021. Surgery was indicated in symptomatic patients and in those with risk factors. The study has been approved by the Clinical Research Ethics Committee of our hospital. RESULTS: We included 124 patients in our study. An elective laparoscopic cholecystectomy was performed in all of them. The mean age was 55,4 years and 61% were women. Of all patients, 65% were symptomatic at diagnosis. Only 3 patients had true polyps (2,4%). All of them were tubular adenomas. The rest of patients were false positives (97,6%). The adenoma size was 11, 6 and 5 mm, respectively. The surgical indication was due to polyp size or due to associated biliary symptoms. CONCLUSION: Ultrasonography is not accurate for the diagnosis of gallbladder polyps. Validation of other complementary tests for the diagnosis of gallbladder polyps in asymptomatic patients could be relevant to avoid unnecessary surgeries.

Pancreatic non-functioning neuroendocrine tumor: a new entity genetically related to Lynch syndrome.

Some pancreatic neuroendocrine tumors (P-NETs) are associated with hereditary syndromes. An association between Lynch syndrome (LS) and P-NETs has been suggested, however it has not been confirmed to date. We describe the first case associating LS and P-NETs. Here we report a 65-year-old woman who in the past 20 years presented two colorectal carcinomas (CRC) endometrial carcinoma (EC), infiltrating ductal breast carcinoma, small intestine adenocarcinoma, two non-functioning P-NETs and sebomatricoma. With the exception of one P-NET, all these conditions were associated with LS, as confirmed by immunohistochemistry (IHC) and polymerase chain reaction (PCR). LS is caused by a mutation of a mismatch repair (MMR) gene which leads to a loss of expression of its protein. CRC is the most common tumor, followed by EC. Pancreatic tumors have also been associated with LS. Diagnosis of LS is based on clinical criteria (Amsterdam II and Bethesda) and genetic study (MMR gene mutation). The association between LS and our patient's tumors was confirmed by IHC (loss of expression of proteins MLH1 and its dimer PMS2) and the detection of microsatellite instability (MSI) using PCR.

Organ-preserving surgery for benign lesions and low-grade malignancies of the pancreatic head: a matched case-control study.

PURPOSE: To compare the postoperative results of various preservative surgery (PS) techniques with those of two types of pancreatoduodenectomy (PD). METHODS: The subjects of this study were 65 patients treated surgically for chronic pancreatitis, or benign or borderline tumors. We defined PS as any of the following: duodenum-preserving pancreatic head resection (DPPHR), uncinatectomy (UC), and cystic tumor enucleation (EN). The two types of PD were Whipple pancreatoduodenectomy (WPD) and pylorus-preserving pancreatoduodenectomy (PPPD). RESULTS: Benign lesions were treated with PD in 41 patients and PS in 24 patients. Whipple pancreatoduodenectomy was performed in 17 patients, PPPD in 24, DPPHR in 20, EN in 3, and UC in 1. The main indication for surgery was chronic pancreatitis (66%). Delayed gastric emptying (DGE) was seen in 41% of patients in the PD group but none in the PS group (P = 0.04). However, there were no differences between the two groups in the incidence of pancreatic fistulas or other complications. Reoperation was required in five of the PD patients, but none of the PS patients. CONCLUSION: Surgical techniques for preserving pancreatic tissue are effective for carefully selected patients with benign pancreatic disorders.

[Cystic neoplasms of the pancreas. Diagnostic and therapeutic management]. / Neoplasias quísticas del páncreas. Manejo diagnóstico y terapéutico.

Management of the cystic lesions of the pancreas is of interest to general and pancreatic surgeons and physicians of other disciplines: gastroenterology, internal medicine, endoscopy, radiology, pathology, etc. The majority of cystic lesions are inflammatory pseudo-cysts. Cystic neoplasms represents only 10% of cystic lesions of the pancreas and 1% of pancreatic tumours. Preoperative diagnosis is crucial given the differences in natural history of the spectrum of benign, malignant, and borderline lesions. Serous cystadenoma is a benign lesion that requires non-surgical management if there are no symptoms. Mucinous neoplasms are premalignant lesions that mainly require pancreatic resection. Despite improved radiographic imaging techniques, definitive diagnosis is only made after studying the resection sample. The pancreatic surgical risk is a problem for the appropriate management of these patients.

Neoplasias quísticas del páncreas. Manejo diagnóstico y terapéutico / cystic neoplasms of the pancreas. Diagnostic and therapeutic management

El manejo de las lesiones quísticas del páncreas interesa tanto al cirujano general y pancreático como a los especialistas en otras disciplinas: gastroenterología, medicina interna, endoscopia, radiología, anatomía patológica, etc. La mayoría de estas lesiones son seudoquistes inflamatorios. Las neoplasias quísticas suponen sólo un 10% del total de las lesiones quísticas del páncreas y un 1% de los tumores pancreáticos. El diagnóstico preoperatorio es crucial, dadas las diferencias en la historia natural del espectro de las lesiones: benignas, malignas y borderline. El cistadenoma seroso es una lesión benigna que no precisa resección quirúrgica, salvo cuando es sintomática. Las neoplasias mucinosas son lesiones premalignas que requieren mayoritariamente resección pancreática. A pesar de los avances en las técnicas de imagen, el diagnóstico definitivo se establece únicamente tras el estudio histológico de la pieza de resección. El riesgo que comporta la cirugía pancreática es un problema asociado al manejo apropiado de estos pacientes (AU)

Management of the cystic lesions of the pancreas is of interest to general and pancreatic surgeons and physicians of other disciplines: gastroenterology, internal medicine, endoscopy, radiology, pathology, etc. The majority of cystic lesions are inflammatory pseudo-cysts. Cystic neoplasms represents only 10%of cystic lesions of the pancreas and 1% of pancreatic tumours. Preoperative diagnosis is crucial given the differences in natural history of the spectrum of benign, malignant, and borderline lesions. Serous cystadenoma is a benign lesion that requires non-surgical management if there are no symptoms. Mucinous neoplasms are premalignant lesions that mainly require pancreatic resection. Despite improved radiographic imaging techniques, definitive diagnosis is only made after studying the resection sample. The pancreatic surgical risk isa problem for the appropriate management of these patients (AU)

[Indications and results of pancreatic surgery preserving the duodenopancreatic region]. / Indicaciones y resultados de la cirugía conservadora en las lesiones localizadas en la cabeza pancreática.

INTRODUCTION: Surgery that preserves the duodenopancreatic region has become well-established in chronic pancreatitis (CP) and some groups have begun to use these techniques to treat benign tumors and even those with uncertain potential malignancy. However, the technical complexity of this type of intervention may be greater than that of cephalic duodenopancreatectomy and complications may be even more frequent and consequently the indications for these procedures are debated. The aim of this study was to evaluate the experience accumulated at our center over the past few years in the use of pancreatic surgery preserving the duodenopancreatic region (PS). MATERIAL AND METHODS. Between 1996 and 2006, we carried out PS in 24 patients with disease localized in the head of the pancreas. PS was defined as any of the following techniques: resection of the head of the pancreas with duodenal preservation (RHPDP), uncinatectomy (UC) and cystic tumor enucleation (EN). RESULTS: RHPDP was performed in 20 patients (83%), UC in 1 (4%) and EN in 3 (13%). Surgery was performed for CP in 11 patients, serous cystoadenoma in 4, intraductal papillary mucinous tumor in 5 and miscellaneous injuries in the four remaining patients. Overall, the series showed 54% morbidity with no post-operative mortality. The median length of postoperative hospital stay was 11 days (7-43). CONCLUSION: After analyzing the experience accumulated over the years, showing nil mortality and acceptable morbidity, we believe that the use of these 3 techniques for preserving the pancreatic parenchyma is useful when their suitability is rigorously indicated. Subsequent studies should look in depth at improving quality of life and physiological effects, depending on the technique used.

Indicaciones y resultados de la cirugía conservadora en las lesiones localizadas en la cabeza pancreática / Indications and results of pancreatic surgery preserving the duodenopancreatic region

Introducción. La cirugía conservadora de la región duodenopancreática ha quedado bien establecida en pancreatitis crónica (PC) e incluso algunos grupos han comenzado a utilizar estas técnicas para tratar tumores benignos y de potencial de malignidad incierto. Ahora bien, la complejidad técnica de este tipo de intervenciones puede ser superior a la de la duodenopancreatectomía cefálica y las complicaciones, incluso más frecuentes; por lo tanto, las indicaciones están en debate. El objetivo de este estudio es evaluar la experiencia acumulada en nuestro centro durante los últimos años en el empleo de la cirugía conservadora (CC) de la región duodenopancreática. Material y métodos. Desde 1996 a 2006, hemos realizado CC por afección localizada en la región cefálica del páncreas en 24 pacientes. Hemos definido CC como cualquiera de las siguientes técnicas: pancreatectomía cefálica con preservación duodenal (PCPD), uncinectomía (UC) y enucleación de tumores quísticos (EN). Resultados. Realizamos PCPD en 20 (83%) pacientes, UC en 1 (4%) y EN en 3 (13%). Los pacientes fueron intervenidos por PC en 11 casos, cistoadenoma seroso en 4, TPMI en 5 y lesiones de estirpe diversa en los 4 casos restantes. En cuanto a la evolución postoperatoria, la serie presenta una morbilidad del 54%, sin mortalidad postoperatoria. La estancia hospitalaria postoperatoria mediana fue de 11 (7-43) días. Conclusiones. En definitiva, tras analizar la experiencia obtenida en estos años, y evidenciar una nula mortalidad con morbilidad aceptable, creemos que la utilización de tres técnicas de preservación de parénquima pancreático es útil mientras éstas sean indicadas con rigor. Estudios posteriores deberían ahondar en la mejoría de la calidad de vida y la repercusión fisiológica según la técnica empleada (AU)

Introduction. Surgery that preserves the duodenopancreatic region has become well-established in chronic pancreatitis (CP) and some groups have begun to use these techniques to treat benign tumors and even those with uncertain potential malignancy. However, the technical complexity of this type of intervention may be greater than that of cephalic duodenopancreatectomy and complications may be even more frequent and consequently the indications for these procedures are debated. The aim of this study was to evaluate the experience accumulated at our center over the past few years in the use of pancreatic surgery preserving the duodenopancreatic region (PS). Material and methods. Between 1996 and 2006, we carried out PS in 24 patients with disease localized in the head of the pancreas. PS was defined as any of the following techniques: resection of the head of the pancreas with duodenal preservation (RHPDP), uncinatectomy (UC) and cystic tumor enucleation (EN). Results. RHPDP was performed in 20 patients (83%), UC in 1 (4%) and EN in 3 (13%). Surgery was performed for CP in 11 patients, serous cystoadenoma in 4, intraductal papillary mucinous tumor in 5 and miscellaneous injuries in the four remaining patients. Overall, the series showed 54% morbidity with no post-operative mortality. The median length of postoperative hospital stay was 11 days (7-43). Conclusion. After analyzing the experience accumulated over the years, showing nil mortality and acceptable morbidity, we believe that the use of these 3 techniques for preserving the pancreatic parenchyma is useful when their suitability is rigorously indicated. Subsequent studies should look in depth at improving quality of life and physiological effects, depending on the technique used (AU)

Emergency operations for nondiverticular perforation of the left colon.

OBJECTIVE: Although diverticulitis is the most common cause of large bowel perforation, other disease may result in left colonic peritonitis. The aim of this study was to evaluate and compare the incidence, management, and outcome of patients with different causes of nondiverticular left colonic perforations. PATIENTS AND METHODS: From January 1992 to September 2000, 212 surgical patients underwent emergency operation for distal colonic peritonitis. Perforations were caused by diverticulitis in 133 patients (63%) and by a nondiverticular process in 79 (37%). Mortality and morbidity in patients with nondiverticular perforation of the distal large bowel its relationship with the general conditions, the grade and the cause of peritonitis were analysed. Four types of surgical procedures were used. Hartmann's procedure was performed in 40 patients (51%); intraoperative colonic lavage, resection, and primary anastomosis (ICL) in 27 patients (34%); colostomy in 7 (9%); and subtotal colectomy in 5 (6%). RESULTS: Perforated neoplasm, the most common cause of peritonitis, was observed in 30 patients, colonic ischemia in 20, iatrogenia in 13, and other causes in 16 patients. One or more complications were observed in 57 patients (72%); among causes of perforation, colonic ischemia was significantly associated with the longest hospital stay and highest mortality. Eighteen patients (23%) died. CONCLUSIONS: Left large bowel perforation by nondiverticular disease is associated with high mortality and morbidity. The prognosis of patients is determined by the development of septic shock and colonic ischemia, as underlying disease, may influence patient survival.